session # c5b total joint replacement and …...clinic • structured clinical interview • brief...
TRANSCRIPT
Total Joint Replacement andPerioperative Behavioral Health
• Brent Fisk, PsyD, Psychologist Resident, Providence Medical Group• Jeri Turgesen, PsyD, ABPP Psychologist, Providence Medical Group• Vanessa Casillas, PsyD, Director of Psychology, Providence Medical Group• Mary Peterson, PhD, ABPP, Chairperson, Graduate Psychology, George Fox University
Session # C5b
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.
Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning ObjectivesAt the conclusion of this session, the participant will be able to:
• Identify psychosocial risk-factors associated with total joint replacement surgical outcome and the role of behavioral health in actively working to mediate risk as a member of the multidisciplinary treatment team.
• Articulate recent findings regarding opioid use/morphine equivalent dosing, pain catastrophizing, emotional health, substance use, etc. and surgical risk/outcome as well as patient satisfaction.
• Identify strategies for integrating a BHP within the perioperative treatment setting and establish a process for meaningful programmatic evaluation through effective data collection.
1. Nguyen, L-C. C., Sing, D. C., & Bozic, K. J. (2016). Preoperative reduction of opioid use before total joint arthroplasty. The Journal of Arthroplasty, 31, S282-S287. http://dx.doi.org/10.1016/j.arth.2016.01.068Reference
2. Pivec, R., Issa, K., Naziri, Q., Kapadia, B. H., Bonutti, P. M., & Mont, M. A. (2014). Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. International Orthopaedics, 38(6), 1159-1165. DOI 10.1007/s00264-014-2298-xReference
3. Nota, S., Spit, S., Voskuyl, T., Bot, A., ahageman, M., & Ring, D. (2015). Opioid use, satisfaction and pain intensity after orthopedic surgery. Psychosomatics, 56(5), 479-485. doi.org/10.1016/j.psym.2014.09.003.
4. Blumenthal, D., Abrams, M., & Nuzum, R. (2015). The Affordable Care Act at 5 years. The New England Journal of Medicine, 372(25), 2451-2458. DOI: 10.1056/NEJMhpr1503614
5. Zarling, B., Yokhana, S., Herzog, D. T., & Markel, D. C. (2016). Preoperative and postoperative opiate use by the arthroplasty patient, The Journal of Arthroplasty, 31, 2081-2084. http://dx.doi.org/10.1016/j.arth.2016.03.061
Bibliography / Reference
Learning AssessmentA learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Total Joint Replacement and Perioperative Behavioral Health
Rapid Expansion of Integrated Services & Behavioral Health
One of the Largest Medical Organizations
in Oregon
48 BHPs in 41 Clinics (Oregon & SW Washington)
Total Joint Replacement and Perioperative Behavioral Health
• IM / FM
• Neurology
• Gen Surgery
• Ortho Surgery
• Oncology
• Cardiology
• ENT
Behavioral Health
Multi-Specialty
+
Total Joint Replacement and Perioperative Behavioral Health
Behavioral Health
Multi-Specialty
+ patient care along
the continuum from
inpatient - outpatient
Opportunity:OPPORTUNITY:
Total Joint Replacement and Perioperative Behavioral Health
Why?Request to help address hospital’s perceived challenges of effectively managing post-operative TJR pain
Simultaneous task of reducing opioid-based medications
12
PATIENT COMPLAINTS:
PAIN ! No More Opioids
Total Joint Replacement and Perioperative Behavioral Health
Affordable Care ActPatient Care
Cost
Re-Admission
Infection
Risks
TJR REALITY:Pain
Hx Rx
Risk
Total Joint Replacement and Perioperative Behavioral Health
System Objectives1 2 3 4 5I.D. Risk Factors
Mediate Surgical Risk
Decrease Opioid Use
Increase Satisfaction
Decrease Readmit
Total Joint Replacement and Perioperative Behavioral Health
Patient Objectives
Increase pt support by stratifying patient risk and providing intervention directly targeted at known risk factors
1 2Increase pt understanding and self-efficacy re: pain and pain management during the perioperative period
Total Joint Replacement and Perioperative Behavioral Health
Program Development• Literature Review
• I.D. Risk Factors Correlating w/ Poor Surgical Outcome
• Data informed “Report Card”• Risk Stratification, Standardized
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[Pre-Surgery Class] [Clinical Interview] [Inpatient Follow-Up] [1-Month Follow-Up]
[6-Week Chart Scrub]
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[Pre-Surgery Class]
• Psychoeducation• Skills Training
In-Person@ Hospital
• Pain Theory & Neurological Process• Psychosocial Stressors• Pain Coping Skills• Pain Self-Efficacy (strategies)
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[Clinical Interview]
• Risk Factors• Screening Tools• Intervention
Pre-AdmitClinic
• Structured Clinical Interview
• Brief Pain Inventory• Pain Catastrophizing Scale• Opioid Risk Tool• PHQ-9
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[Clinical Interview]
• Risk Factors• Screening Tools• Intervention
Pre-AdmitClinic
Low Moderate High• Coping
Skills
• Have a Nice Day
• Brief Intervention
• Review Subjective Complaints
• Possible System Intervention
• Additional Intervention (Office Visits)
• System Intervention (Inpatient -Outpatient Care Teams)
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[Inpatient Follow-Up]
• Intervention• Additional Support
Bedside• Pain Coping Assessment• Practice Relaxation Skills• Interdisciplinary Consultation
Total Joint Replacement and Perioperative Behavioral Health
Intervention
[1-Month Follow-Up]
[6-Week Chart Scrub]
• Pain Coping Assessment• Brief Pain Inventory• Reminder: Coping Skills• MED
Total Joint Replacement and Perioperative Behavioral Health
Results2015 – 2018 n = 347
Low Moderate High
89% 10% 1%
2017 – 2018n = 63
87% 11% 2%
Total Joint Replacement and Perioperative Behavioral Health
ResultsDepression Helplessness MED 1mo/6wk
.56 .5 .54 /.56Hx of OpioidUse - Length
Opioid Refill Requests 6wk
.5 .54
Total Joint Replacement and Perioperative Behavioral Health
ResultsDepression MED 6wk
.66 .51Pain Catastrophizing
Pain Helplessness .54.59
Total Joint Replacement and Perioperative Behavioral Health
Results
71.21%
22.73%
4.55% 0% 0%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Strongly Agree Agree Neutral Disagree Strongly Disagree
I understand the role of BHC in pre/post-operative surgical care
Total Joint Replacement and Perioperative Behavioral Health
Results
56.06%
31.82%
10.61% 0% 0%0%
20%
40%
60%
80%
100%
Strongly Agree Agree Neutral Disagree Strongly Disagree
I learned new strategies to help with my post-operative recovery
Total Joint Replacement and Perioperative Behavioral Health
Results
46.97% 43.94%
7.58% 0% 0%0%
20%
40%
60%
80%
100%
Strongly Agree Agree Neutral Disagree Strongly Disagree
I learned new strategies to help my pain management
Total Joint Replacement and Perioperative Behavioral Health
Results
63.64%
28.79%6.06% 0% 0%
0%
20%
40%
60%
80%
100%
Strongly Agree Agree Neutral Disagree Strongly Disagree
The approach we used made sense to me
Total Joint Replacement and Perioperative Behavioral Health
Results
63.64%
27.27%7.58% 0% 0%
0%
20%
40%
60%
80%
100%
Strongly Agree Agree Neutral Disagree Strongly Disagree
I intend to use what I learned during visits
Total Joint Replacement and Perioperative Behavioral Health
Results
75.76%
21.21% 1.52% 0% 0%0%
20%
40%
60%
80%
100%
Very positive Positive Neutral Negative Very Negative
Overall I would rate my experience with the surgical BHC...
@ inpatient = 74% (84% = helpful)
@ 1 month = 57%
Total Joint Replacement and Perioperative Behavioral Health
Results
CopingSkills
Total Joint Replacement and Perioperative Behavioral Health
Future• Continue to see 100% TJR pts
• Expansion request to other high-risk surgical categories
• Expansion intervention: bio feedback
Total Joint Replacement and Perioperative Behavioral Health
Questions
Session Evaluation
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Thank you!